Maison Law helps injury victims in California through the workers’ compensation process. We can help you understand your rights and what resources you have when you get hurt at work. Even though you can file a workers’ comp claim, you might run into issues with your medical treatment where the insurance company denies your claim and coverage for said injury. If you find yourself in this situation, we can help. Contact us today for a free consultation.
Why Would Workers’ Compensation Deny Your Medical Treatment?
One of the major parts of any workers’ comp claim is when you go to your doctor and get treatment for your injury. However, your employer’s workers’ comp insurance doesn’t necessarily have to approve the treatment. In fact, if they see fit, they might deny the recommended treatment. Here’s a few of the more common factors that would cause them to do this:
- Lack of medical proof – If you don’t have enough medical evidence showing your injury is related to work, the insurance company might deny your treatment.
- Not reporting on time – If you miss the 30 day deadline to tell your employer about your injury, the insurance company might claim it didn’t happen at work and deny your treatment.
- Pre-existing conditions – If the workers’ comp insurance thinks your injury is because of a condition you had before the accident, they may deny the treatment, claiming it wasn’t caused by your job.
- Not following your treatment plan – If you miss medical appointments or don’t follow your treatment plan, the insurance company might stop covering your medical care.
- Using an unapproved doctor – If you go to a doctor that isn’t approved by the workers’ comp insurance, they might deny paying for that treatment.
- Doubting your claim – If the insurance company thinks you’re exaggerating your injury or being dishonest in some way, they might deny your medical care.
- The treatment isn’t covered – Some treatments might not be covered, especially if the insurance company doesn’t think they’re “medically necessary.”
- Gaps in treatment – If there’s a big gap between when you got injured and when you seek treatment, they might deny it, thinking it’s unrelated to the original injury.
- Missing paperwork – If your claim is incomplete or the paperwork is incomplete, the insurance company can deny the treatment for administrative reasons.
- Employer disputes – If your employer disputes your claim, saying the injury didn’t happen at work, insurance might deny your treatment until it’s sorted out.
Obviously, you never want to go through a situation where your medical treatment is denied or not covered. Being injured is difficult enough on its own without worrying about how you’ll pay your bills. Luckily, our team is experienced with this process and can help you with an appeal.
What’s the Appeals Process For Denial of Medical Treatment?
The good news, relatively speaking, is that a denial of medical treatment by the insurance company isn’t the end of the line. In California, there’s an appeals process you can go through to try to either reverse the decision or at least get more information:
- Independent Medical Review (IMR) – If the insurance company denies your treatment after their review, you can ask for an Independent Medical Review (IMR). This means another doctor, who doesn’t work for the insurance company, will look at your case and decide if you should get the treatment. You have 30 days to request an IMR after you’re denied.
- Filing the appeal – If the IMR also denies your treatment, you can appeal to the Workers’ Compensation Appeals Board (WCAB). To do this, you’ll need to submit paperwork that starts the appeal. It could lead to a hearing.
- Hearing with a judge – At the hearing, a workers’ compensation judge will listen to you and the insurance company. You can show why you need the treatment. The judge will make a decision based on the evidence from both sides.
- Appealing that decision, if necessary – If the judge denies your treatment, you can file another appeal asking for a reconsideration. If you still don’t agree with the outcome, you can appeal to a higher court, but if you reach this point, you might have better luck with a lawsuit.
As with any appeal, this can be an incredibly tough process. And remember, you’re still probably dealing with your injuries and other losses. Our team has extensive experience and resources to help you through the entire process to make sure you’re able to get the medical care you need.
Support and Guidance in California Workers’ Compensation Claims
Being denied medical treatment after a workplace injury is incredibly frustrating, but with Maison Law on your side, you know that you’ll get the legal guidance and support you need. Our team of California workers’ compensation lawyers know how the system and where we can leverage our experience to make sure you get the results you need. Contact us today for a free consultation to learn more.
